Psychosocial Impact of Incontinence
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
Loss of control of urine, gas and stool can have a significant impact on the social well-being of affected women. It is a social and hygienic problem and leads to social distress. Urinary and fecal incontinence and related psychosocial distress constitute a spectrum related to the actual severity of the loss of control and to the woman's perception of her disability. Great stigma and shame is associated with urinary and fecal incontinence.
The purpose of this document is to provide a better understanding of this devastating situation and provide management. Forums and management guidelines hope to provide the incentive for social and psychological programs to help women who are unfortunate victims of the situation.
Incontinence is a complex phenomenon with multiple causative factors, including psychogenic causes. Psychiatric analyses of women with urinary or fecal incontinence are depression, anxiety, and abnormal levels of situational life stresses. It is likely that psychologic changes are related to the symptom and related disability and distress than to specific urogynecologic conditions. Many studies suggest that psychologic factors associated with urinary or fecal incontinence can be modified with therapy (1).
Effect on Individual: Feeling of insecurity, anger, apathy, dependence, guilt, indignity, feeling of abandonment, shame, embarrassment, depression and denial are common. Women feel loss of self-confidence and self-esteem. Lack of personal hygiene make the situation worse and sexual difficulties are common. Women tend to get socially disengaged and socially isolated. Psychologic and functional decline prevails and potential for institutionalization occurs.
Effect on Family: Economic worries for the families are enormous, caregiver burden and emotional stress on the families is phenomenal. Health deterioration of primary caregiver and impaired interpersonal relationships are common. Potential for abuse or neglect is real. Decision to institutionalize and delayed discharge from institutional care are frequently seen.
Effect on Healthcare Professional: Negative feelings and behaviors toward patients with urinary and fecal incontinence sometimes are noticed. Patients are seen as extra care responsibilities and "Burn-out" syndrome is prevalent among the healthcare providers of the women with urinary and fecal incontinence. Reaction formation such as overindulgence, excessive permissiveness and excessive caring is not uncommon.
Urinary and fecal incontinence can lead to such disability and dependency that family or home caregivers have difficulty coping and responding to increased demands. Incontinence may be the last straw in a family's attempts to care for disabled woman. It is a major factor leading to institutionalization and may be secondary reason for many more. Wyman et al (1990) examined epidemiologic and clinical studies addressing the psychosocial impact of urinary incontinence on community-dwelling women (2). They noted wide variations among studies regarding patient populations surveyed, methods of evaluation, and definitions used. Reports of interference with social activities ranged from 8% to 52%. Areas affected included social, domestic, physical, occupational, and leisure activities. Sufferers may give up or restrict certain household chores, church/temple/holy-places attendance, shopping, traveling, vacations, physical recreation, entertainment events outside the home, and hobbies. They may avoid activities outside the home if they are unsure of restroom locations. Some incontinent women become increasingly isolated as they limit social activities and social contacts. Even incontinent homebound women, have significantly fewer social interactions, particularly with family members.
Spousal relationships appear to be most impaired, perhaps because of an additional adverse effect on sexual relationships. It is widely accepted that urinary and fecal incontinence is under-recognized and under-treated. Fewer than half of people with incontinence in the community consult their healthcare providers about the problem. The reasons for this include embarrassment, availability of absorbent products, low expectations of benefit from treatment, and lack of information regarding options for treatment.
The close anatomic proximity of the bladder, urethra, and rectum with the vagina allows for an association between lower urinary tract or anorectal dysfunction and sexual difficulties. The effects can be bidirectional; sexual activity can cause or aggravate bladder or anorectal problems, and bladder or anorectal problems can lead to sexual dysfunction. The association between urologic symptoms and sexual problems may occur in several ways. Urinary symptoms may be a direct cause of sexual difficulties, where none previously existed. Alternatively, urinary symptoms may be used (consciously or unconsciously) as an excuse to avoid sexual contact in the presence of a preexisting but unacknowledged sexual problem. Declining general health of the woman may affect sexual activity. Thus, many complex factors affect the quality of sexual function (3).
Sexual function may be positively or negatively affected by the surgical treatment of urinary incontinence. Deterioration is many times seen after extensive pelvic floor repair.
Despite the prevalence of urinary incontinence, studies of its economic impact are scarce, primarily because of the absence of reliable prevalence, risk factor and cost data and because of wide diversity of treatment methods. Estimated costs of urinary incontinence should include direct and indirect costs, as well as costs of treating complications related to incontinence. Direct costs are the resources from the economy used to diagnose, treat, care for, and rehabilitate incontinent patients. Indirect costs of incontinence include lost productivity, consequences of incontinence ranging from skin ulcers to mortality, and the cost of time spent by unpaid caregivers. The sum of direct and indirect costs of urinary incontinence reflects the total economic burden on the entire economy (4).
Direct Costs: It includes diagnostic and evaluation costs, physical consultation and examination. Treatment costs include surgery and drugs, routine care costs - nursing labor, supplies and laundry. Rehabilitation costs include nursing labor, supplies, incontinence consequence costs- skin breakdowns, urinary tract infections, injury and additional nursing home admissions and longer hospital stays.
Indirect Costs: Time costs of unpaid caregivers for treating and caring for incontinent women. Loss of productivity because of morbidity and mortality is enormous.
Assessment of psychological well-being:
Increased risk of pelvic dysfunction, stress incontinence, anal incontinence, dyspareunia and vulval problems following the repair are increased in incidence and duration. The prevalence and severity, including any related psychosocial ill-health in this population, needs further definition. Impaired social functioning is assessed by analyzing any delay resulting from its interference with usual post partum social activities (5). Each participant was questioned about the postpartum interval to resuming housework, employment, social networking leisure activities and sexual relationship with partner. All social responses were categorized into postpartum intervals. Maternal social functioning was classified as unimpaired if the mother carried out her pre-pregnancy and postpartum social commitments within the average post-partum interval considered to be usual for each of these social functions (category 1). Categories 2, 3 and 4 were considered as increasing degrees of impaired social health as represented below:
- Function resumed 0-12 weeks postpartum (normal range)
- Function resumed 13-24 weeks postpartum (mild impairment)
- Function resumed 25-36 weeks postpartum (moderate impairment)
- Function resumed after 37 weeks postpartum (severe impairment)
The grading of the severity of psychosocial morbidity makes it easier to quantify, and its feasibility for assessing obstetric outcomes should be evaluated prospectively (6). In the presence of stress incontinence and dyspareunia bio-psychosocial morbidity could be severe. Pelvic dysfunction can contribute to relationship problems with their infant or with their partner. The approach for assessing the overall predicted morbidity and perceived maternal needs associated with pelvic dysfunction could have role in the management of these patients and development of relevant support services.
At least for the short term, quality of life and other second-order benefits must be considered if continence rehabilitation is to be cost-effective. Awareness about vesico-vaginal fistula as a treatable condition should be encouraged in the community. It is very helpful in improving the status of women in the society by encouraging them to learn about the appropriate care. Maternal health interventions are among the most cost effective investments in health. Good maternal health services can strengthen the entire health system. For every woman who dies in childbirth, 30 to 50 women suffer injury, infection or disease. Pregnancy related complications are among the leading causes of death and disability for women age 15 - 49 in developing countries. Safe Motherhood is a vital economic and social investment. Safe Motherhood means ensuring that all women receive the care they need to be safe and healthy throughout pregnancy and childbirth. The importance of skilled care during pregnancy and childbirth is vital and essential. Skilled attendants mean successful outcomes. Maternal health and newborn health both should be the centre of policy and action.
- Borello-France D, Burgio KL, Richter HE et al. Fecal and urinary incontinence in primiparous women. Obstet Gynecol 2006;108:863-872
- Klein MC, Kaczorowski J, Firoz T et al. A comparison of urinary and sexual outcomes in women experiencing vaginal and cesarean births. J Obstet Gynaecol Can 2005;27:332-339
- MacLennan AH, Taylor AW, Wilson DH et al. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. Br J Obstet Gynecol 2000;197:1460-1470
- Ogden J. Health psychology: A textbook. Second edition. Buckingham, UK, Open University Press, 2000
- Brown S, Lumley J. Physical health problems after childbirth and maternal depression at six to seven months postpartum. Br J Obstet Gynecol 2000;107:1194-1201
- Sargent HA, O'Callaghan F. Predictors of psychological well-being in a sample of women with vulval pain. J Reprod Med 2009;54:109-116
Dedicated to Women's and Children's Well-being and Health Care Worldwide